Kevin Libin: Doctors favour junkies over smokers

Smokers should be so lucky as to have the political influence that heroin junkies clearly enjoy. When the Canadian government was pursuing its court challenge against Vancouver’s Insite safe injection clinic for heroin users—which it recently lost at the Supreme Court—dozens of doctors and scientists rose up to protest. Stephen Hwang, a top researcher at the University of Toronto, called the government’s hostility to Insite “an alarming example of a recent trend towards the increased politicization of science.”

But if the Conservative government stands guilty of politicizing science, it has company: public health doctors and researchers who have been aggressively fighting against another kind of harm reduction for years. Tobacco harm reduction takes much the same approach as with illegal drugs: Taking for granted that certain addicts are hooked, and that rather than writing them off or pretending that lecturing them will make them kick, our public health is better off by working to minimize the risks their addictions pose to their health and safety. For advocates of Insite, that means providing heroin addicts with clean needles, a safe, secure environment—a refuge from the dirty alleys—and supervision by health professionals who can ensure the dosages are safe and respond immediately to any bad reactions. Wherever you stand on the ethics of it, there is reasonable scientific evidence that Insite actually saves lives and pretty much none that it does any harm. That’s what the doctors tell us, anyway: Harm reduction for heroin works.

Tobacco harm reduction is a much simpler matter than all that. You don’t even need clinics. What you do need is to acknowledge that there’s a stubborn portion of the population that—as above—is hard-core addicted to nicotine and that rather than writing them off or pretending that lecturing them will make them kick, our public health is better off by working to minimize the risks their addictions pose to their health and safety. And there are ways to do that. Promoting smokeless tobacco is a big one, since so much of the mortal danger that nicotine addicts risk comes from the carcinogens in smoking. E-cigarettes, or tobacco vapourizers, are another major improvement over smoking. And in Sweden, where millions of smokers have switched to a under-the-lip pouch of tobacco called snus, lung cancer rates and heart disease rates have fallen to some of the lowest in Europe. Just as with Insite, there is solid evidence showing that these lower risk products lead to increases in public health.

As a 2007 paper published in the International Journal of Drug Policy concluded: “Applying harm reduction principles to public health policies on tobacco/nicotine is more than simply a rational and humane policy…It has the potential to lead to one of the greatest public health breakthroughs in human history by fundamentally changing the forecast of a billion cigarette-caused deaths this century.”

Yet all of these products have been dismissed out of hand by numerous public health groups who have determined, with the same resolve and naiveté as the War on Drug types, to wipe all tobacco off the face of the earth. The American Cancer Association, the American Heart Association, and even the American Lung Association have ruled out promoting Tobacco Harm Reduction through comparatively safer products. Since, they say, all these products may still potentially contain some health risk—no matter how vanishingly minimal—they are condemned as unsafe substitutes.

Scientifically speaking, some of them actually are very literally safe substitutes: Snus, which is low in carcinogenic nitrosamines, has yet to be linked to any cancers at all. And e-cigarettes, though still being studied, appear to prevent far more cancers than they would ever cause. In any case, the point of harm reduction, right there in its name, is not to try, fruitlessly, to eliminate harm altogether but gradually reduce it. They don’t need to be “safe.” It’s just better if they’re safer. Even Greg Connolly, the lead researcher and the director of the Tobacco Control Research program at Harvard University has said “if we can get everyone to switch to smokeless [tobacco] tomorrow, it would be a public-health miracle.” And the slight drop in American smoking rates since 2005 reported last month by the Centers for Disease Control reflects directly the take-up of snus products and e-cigarettes in that country, says Carl Phillips, an epidemiologist and director of TobaccoHarmReduction.org.

Professor Phillips was researching Tobacco Harm Reduction at the University of Alberta until he quit last year after a nasty campaign of hounding and harassment by the medical faculty there who could not bear the idea that anyone might suggest using any kind of tobacco at all, even if it might reduce people’s risk of getting cancer or heart disease. “We do not want to be a part of anything that increases the social legitimacy and normalization of a product that technically should not be on the market because it’s killing people,” Dr. Charl Els, a U of A psychiatrist and the Alberta director of Physicians for a Smoke Free Canada, said at the time.

And yet that’s exactly what Insite does, by normalizing an illegal product that has the potential to kill people who use it in dangerous ways. And many tobacco users use nicotine to self-medicate for certain psychiatric problems, whether that’s post-traumatic stress disorder, schizophrenia, attention deficit disorders and depression. Smokers aren’t just undisciplined, uncouth slobs who deserve what they get. Yet for whatever reason, discriminatory doctors and public health officials have championed help for the downtrodden heroin users of East Vancouver, while actively fighting the promotion of harm-reduction to nicotine addicts who risk their lives by relying on cigarettes. That’s not just hypocritical, it’s actually killing people.